Download Inadvertent Mix-Up of Morphine and Hydromorphone

Patient Safety Advisory
Produced by ECRI Institute & ISMP under contract to the Patient Safety Authority
Inadvertent Mix-Up of Morphine and Hydromorphone: A Potent Error
M
orphine is the quintessential opioid agonist and
the accepted standard against which other
opioids are tested in controlled clinical trials.1 However, because some patients cannot tolerate
morphine or have conditions such as renal or hepatic impairment that may impact its use, another
opioid may be needed as a replacement drug.
Hydromorphone (Dilaudid®) is a common alternative
to morphine for treating pain. When a patient requires an alternative to morphine, the analgesic
equivalence between morphine and the alternative
needs to be considered. The most common hospitalbased source of medication errors involving potency
is when a patient is switched from morphine to
hydromorphone.2 Hydromorphone by any route is
significantly more potent than morphine, as indicated by the following:3
A few reports submitted to PA-PSRS involved breakdowns in the communication of drug orders, such as
the following:
A doctor and nurse were at the patient’s bedside. The doctor spoke about considering
Dilaudid, but at the command post the doctor
gave a verbal and written order for morphine.
The nurse stated that she did not hear the
verbal order and Dilaudid had been given.
The patient became lethargic and diaphoretic,
and the rapid response team was called.
Narcan was given and patient improved
within a few minutes.
•
Oral hydromorphone is approximately four
times more potent than oral morphine.
― For example, 7.5 mg hydromorphone
per os (PO) = 30 mg morphine PO.
A patient’s pre-op orders were continued
along with the post-op orders which were
written. The patient had been ordered
Dilaudid IV pre-op and morphine IM post op.
A nurse continued to give Dilaudid IV. The
patient developed respiratory distress and
was transferred to the telemetry unit.
•
Parenteral hydromorphone is approximately
seven times more potent than parenteral
morphine.
― For example, 1.5 mg hydromorphone
intravenous (IV) = 10 mg morphine IV.
Some of the errors reported to PA-PSRS, such as the
following, occurred when the pharmacy department
dispensed the wrong medication or replenished an
automated dispensing cabinet (ADC) or unit stock
with the wrong medication:
•
Parenteral hydromorphone is approximately
20 times more potent than oral morphine:
― For example, 1.5 mg hydromorphone
IV = 30 mg morphine PO.
In addition, name similarities have led to inadvertent
mix-ups between morphine and hydromorphone,
or the mistaken belief that hydromorphone is the
generic name for morphine.4 Analysis of wrong drug
errors submitted to PA-PSRS shows that mix-ups
between these two medications outnumber all other
pairs of medications (see “Common Medication
Pairs that Contribute to Wrong Drug Errors” elsewhere in the September 2007 issue of the PA-PSRS
Patient Safety Advisory Advisory). When errors occur with these two medications and the same milligram dose is given (e.g., hydromorphone 5 mg IV
given instead of morphine 5 mg IV), the potential for
harm exists. In the previous example, 5 mg of parenteral hydromorphone is equivalent to 35 mg of
parenteral morphine.
©2007 Pennsylvania Patient Safety Authority
A patient was ordered morphine for pain.
There was a possibility that the patient
received Dilaudid instead of morphine.
Morphine and Dilaudid were later found
mixed in the morphine drawer in the ADC.
No injury to patient.
This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 4,
No. 3—September 2007. The Advisory is a publication of the Pennsylvania
Patient Safety Authority, produced by ECRI Institute & ISMP under contract
to the Authority as part of the Pennsylvania Patient Safety Reporting
System (PA-PSRS).
Copyright 2007 by the Patient Safety Authority. This publication may be
reprinted and distributed without restriction, provided it is printed or distributed
in its entirety and without alteration. Individual articles may be reprinted in
their entirety and without alteration provided the source is clearly attributed.
This publication is disseminated via e-mail. To subscribe, go to https://www.
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To see other articles or issues of the Advisory, visit our Web site at
http://www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar.
Page 1
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 3 (September 2007)
Inadvertent Mix-Up of Morphine and Hydromorphone: A Potent Error (Continued)
The unit’s ADC was restocked with morphine
4 mg injection instead of Dilaudid 4 mg injection. A patient received two doses of morphine
instead of the ordered medication of Dilaudid.
•
The most common care areas where this
mix-up occurred were medical/surgical
units, medical/oncology units, emergency
departments (EDs), and telemetry units.
Seventy-one percent of reports of mix-ups between
morphine and hydromorphone indicate that the errors occurred when these medications were obtained from unit stock (i.e., ADCs, medication
carts), prior to administration. Examples include the
following:
•
Elderly patients (patients 65 years and
older) were involved in 34% of the reports.
During the 3-11 shift change report, the oncoming nurse was told that a patient was receiving morphine [patient-controlled analgesia
(PCA)]. Upon checking the PCA settings, the
patient asked why he was now on morphine,
as he was getting no relief. The nurse
checked orders and found that the patient
should have been on Dilaudid PCA. The incorrect medication had been removed from
the ADC and had been infusing for approximately five hours.
Dilaudid 4 mg was removed from narcotic
drawer instead of morphine 4 mg. The nurse
attempted to scan the drug but aborted the
effort when the computer did not accept the
scan and thought it was a malfunction. The
patient received the medication but remained stable.
In the emergency room, a physician ordered
Dilaudid for the patient. Upon discharge, the
nurse removed the medication from the
automated dispensing cabinet and unknowingly gave the patient morphine to take
home, thinking it was Dilaudid. After completing a discrepancy check with Pyxis, the
error was discovered. The patient was called
at home, but the patient had already taken
the medication. There were no complications per the patient.
Further analysis of these wrong drug reports involving either morphine or hydromorphone shows that:
•
Of all wrong drug error reports that include
morphine and/or hydromorphone, 36% involve a mix-up between those two drugs.
•
Of wrong drug reports that involve these two
drugs, 62% show morphine as the prescribed medication and hydromorphone given
in error.
Page 2
Adverse events related to inadvertent mix-up of these
two medications have occurred elsewhere. In a tragic
event that took place in Canada, a 69-year-old patient
was given 10 mg of hydromorphone IM instead of
10 mg of morphine.5 The patient presented to the ED
with a chest injury sustained while horseback riding.
Prior to discharge, the ED physician wrote an order
for morphine 10 mg IM for pain, but hydromorphone
was mistakenly selected from the narcotic drawer.
Both hydromorphone and morphine were stocked in
1 mL, 10 mg/mL ampuls. Based on equianalgesic
dose conversion charts, the patient, who was likely
opiate-naïve, received an equivalent dose of about
60 to 70 mg of morphine. Shortly after the patient was
discharged, the nurse discovered the error after a
scheduled narcotic count showed a discrepancy between the two drugs. Hospital staff immediately tried
to contact the patient and finally located him in a rural
hospital close to his home. The patient’s condition had
rapidly deteriorated until he arrested. Despite rescue
efforts, the patient died.6
Another example includes an error in a hospital,
where the darkness of the room during laser surgery
(i.e., all lights were off except a spotlight) contributed
to mix-ups between look-alike, prefilled syringes of
morphine and hydromorphone.7 (See photos of
look-alike syringes.) In a third case, hydromorphone 4 mg cartridges were mixed in with similar
looking morphine 4 mg cartridges in the floor stock
narcotic cabinet. The hydromorphone was administered instead of morphine for postoperative pain
control. Unfortunately, two hours later the patient
was found dead.8
The Joint Commission has turned its attention to the
confusion between these names and the potential
harm that can occur, as is reflected in its National
Patient Safety Goal 3C, which states that organizations, in order to improve the safety of using medications, “identify and, at a minimum, annually review a
list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the
interchange of these drugs.”9 The Joint Commission
has included morphine and hydromorphone as a
name pair that both acute care and ambulatory care
sites should consider adding to their look-alike/
sound-alike lists.
©2007 Pennsylvania Patient Safety Authority
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 3 (September 2007)
Inadvertent Mix-Up of Morphine and Hydromorphone: A Potent Error (Continued)
Figure. Look-Alike
Morphine and
Hydromorphone
Syringes.
Images provided
courtesy of ISMP.
Safe Practices
Mix-ups between morphine and hydromorphone are
the most common and potentially serious errors that
can occur involving two high-alert drugs. This risk
exists in almost every facility in Pennsylvania. Assume that this error will eventually happen in your
facility, and consider the following steps to reduce
the risk of patient harm.7
Limit access. Reduce stock amounts of hydromorphone wherever possible, and eliminate it from floor
stock if usage is low. For example, some health systems where this type of error occurred removed all
hydromorphone from every ED in the health region.
If the drug is needed on patient care units, only the
2 mg/mL strength is available, except in palliative
care units. The pharmacies in these health systems
continue to stock hydromorphone for compounding
PCA or continuous infusions.
Reduce options. If both drugs are available in patient care units, avoid stocking morphine and
hydromorphone in the same strength. For example,
since both drugs are available in 2 mg and 4 mg
prefilled syringes, stock 2 mg of hydromorphone
and 4 mg of morphine (but not vice versa, since
4 mg of hydromorphone could be an excessive
dose). If the drugs are stored in an ADC, consider
allowing access to morphine via an override function
in emergencies, but require pharmacy order review
before removing a first dose of hydromorphone. Also,
be sure to store each medication in a separate, individual bin or drawer in the ADC or unit-stock to help
prevent drug selection errors. In the pharmacy, segregate prefilled syringes and vials of these drugs,
especially if they contain the same concentration.
Reduce “look-alike” potential. When possible, use
tall man lettering to emphasize the lettering, like
“HYDRO” or “PHONE” on pharmacy labels, auxiliary
labels, medication administration records, preprinted
orders and drug listings on prescriber and pharmacy
order entry screens or ADCs. Consider adding label
reminders on hydromorphone indicating the brand
©2007 Pennsylvania Patient Safety Authority
name equivalent, “DILAUDID,” to help prevent confusion. Some ADCs may also offer the capability of
asking “This is DILAUDID. Is that correct?” when
nurses retrieve hydromorphone.10
Employ technology. Technological solutions (e.g.,
bar coding, automated dispensing technology that requires pharmacy order screening prior to dose retrieval) may reduce, but not eliminate, the risk of mix-ups.
Require redundancies. Require an independent
double check before administering IV narcotic
doses. Since nurses routinely obtain narcotics from
floor stock, the typical pharmacist-nurse double
check is not in place (as it is with patient-specific
doses dispensed from the pharmacy). Some ADCs
can be programmed to require a licensed “witness”
when selected narcotics are removed, or when the
override feature is used to access selected narcotics. Reminders can also appear on the screen.
Monitor patients. Implement policies that specify
the scope, frequency, and duration of monitoring
that should occur before discharging patients who
have just received a parenteral narcotic.
Educate staff. Provide safety information on the
use of potent narcotics via newsletters and inservice meetings. Educate staff about the differences between hydromorphone and morphine, as
some of the reported mix-ups have been due to the
mistaken belief that hydromorphone is the generic
name for morphine.
Educate patients. Prior to administration of a narcotic, repeat the name of the medication out loud to
the patient as another source of confirmation.
Notes
1. Dunbar PJ, Chapman CR, Buckley FP, et al. Clinical analgesic
equivalence for morphine and hydromorphone with prolonged
PCA. Pain 1996 Dec;68(2-3):265-70.
2. Pain Task Force, Massachusetts General Hospital. Opioid
potency and equianalgesia: critical facts [online]. 2005 Mar [cited
2007 Feb 2]. Available from Internet: http://www.mgh.harvard.
edu/PainRelief/Equianalgesia.pdf.
Page 3
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 3 (September 2007)
Inadvertent Mix-Up of Morphine and Hydromorphone: A Potent Error (Continued)
3. Approximate equianalgesic dosing of opioid analgesics in
adults. In: Facts and Comparisons® 4.4.120 [database on
CD-ROM]. St. Louis (MO): Wolters Kluwer Health, Inc.
4. Institute for Safe Medication Practices. Safety issues with patient-controlled analgesia: part I—how errors occur. ISMP Medication Safety Alert! Acute Care Edition. 2003 Jul 10;(8)14:1-4.
5. Institute for Safe Medication Practices. An omnipresent risk of
morphine-hydromorphone mix-ups. ISMP Canada Safety Bulletin.
2004 Jun;4(6).
6. Institute for Safe Medication Practices. Risk of deadly mix-up
exists in most hospitals. ISMP Medication Safety Alert! Acute
Care Edition. 2004 Jul 1;9(12):1-2.
7. Institute for Safe Medication Practices. Cutting errors out of the
operating room—part II. ISMP Medication Safety Alert! Acute
Care Edition. 2002 Mar 20;(7)6.
8. Confusion between opioid analgesics results in deaths [online].
USP Quality Review 1995 Feb [cited 2007 Feb 2]. Available from
Internet: http://www.usp.org/hqi/practitionerPrograms/newsletters/
qualityReview/qr461995-02-01a.html.
9. Joint Commission. 2007 national patient safety FAQs [online].
[cited 2007 Jan 29.] Available from Internet: http://www.
jointcommission.org/NR/rdonlyres/C92AAB3F-A9BD-431C-862811DD2D1D53CC/0/LASA.pdf.
10. Institute for Safe Medication Practices. Safety issues with
patient-controlled analgesia: part II—how to prevent errors.
ISMP Medication Safety Alert! Acute Care Edition. 2003 Jul 24;
8(15):1-3.
Self-Assessment Questions
1.
The approximate equianalgesic dose of oral hydromorphone
is which one of the following?
A. One-tenth the dose of oral morphine
B. One-fourth the dose of oral morphine
C. Equal to the dose of oral morphine
D. Twice the dose of oral morphine
E. Ten times the dose of oral morphine
2.
The approximate equianalgesic dose of parenteral
hydromorphone is which one of the following?
A. One-tenth the dose of parenteral morphine
B. One-fourth the dose of parenteral morphine
C. Equal to the dose of parenteral morphine
D. Twice the dose of parenteral morphine
E. Seven times the dose of parenteral morphine
3.
Conditions that may contribute to harm from mix-ups
between morphine and hydromorphone include all EXCEPT
which one of the following?
A. The more potent morphine is given instead of
hydromorphone
B. The location of care areas (e.g., the emergency
department)
C. The similarity in the names of the medications
D. Breakdown in the communication of drug orders
4.
Which of the following steps would not help to reduce the risk
of patient harm with the use of morphine and hydromorphone?
A. Reducing the number of available concentrations of
both drugs
B. Allowing unlimited stock of these medications
C. Using tall man lettering to differentiate hydromorphone
from morphine
D. Learning about the differences between both medications
The Patient Safety Authority works with the Pennsylvania Medical Society to offer
AMA PRA Category 1 Credits™ for selected portions of the PA-PSRS Patient Safety Advisory through the online publication Studies in Patient Safety: Online CME Cases. Go to
http://www.pamedsoc.org/studies to find out more about patient safety CME opportunities.
Page 4
©2007 Pennsylvania Patient Safety Authority
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 3 (September 2007)
The PA-PSRS Patient Safety Advisory is issued quarterly, with periodic supplements.
Previous issues are available on the Patient Safety Authority Web site at http://www.
psa.state.pa.us. Click on “Advisories and Related Resources” in the left-hand menu bar.
Selected articles in previous issues include:
•
“Airway Fires during Surgery” (March 2007)
•
“Bone Cement Implantation Syndrome” (December 2006)
•
“Delays in the OR: Stress between ‘Running Two Rooms’ and ‘Time Outs’”
(September 2006)
•
“Doing the ‘Right’ Things to Correct Wrong-Site Surgery” (June 2007)
•
“I’m Stuck and I Can’t Get Out! Hospital Bed Entrapment” (December 2006)
•
“Improving Safety of Telephone or Verbal Orders” (June 2006)
•
“Mismanagement of Expressed Breast Milk” (June 2007)
•
“Safety in Using Promethazine (Phenergan)” (March 2007)
•
“Skin Tears: The Clinical Challenge” (September 2006)
•
“Who Administers Propofol in Your Organization?” (March 2006)
©2007 Pennsylvania Patient Safety Authority
Page 5
Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 3 (September 2007)
An Independent Agency of the Commonwealth of Pennsylvania
The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical
Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as
contractor for the PA-PSRS program, is issuing this publication to advise medical facilities of immediate
changes that can be instituted to reduce Serious Events and Incidents. For more information about the
PA-PSRS program or the Patient Safety Authority, see the Authority’s Web site at www.psa.state.pa.us.
ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of
applied scientific research in healthcare to uncover the best approaches to improving
patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries
experience and independence with the objectivity of evidence-based research. More
than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in
patient safety improvement, risk and quality management, and healthcare processes,
devices, procedures and drug technology.
The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization
dedicated solely to medication error prevention and safe medication use. ISMP provides
recommendations for the safe use of medications to the healthcare community including
healthcare professionals, government agencies, accrediting organizations, and consumers.
ISMP's efforts are built on a non-punitive approach and systems-based solutions.
Page 6
©2007 Pennsylvania Patient Safety Authority